PAYROLL DEDUCTION AUTHORIZATION



PAYROLL DEDUCTION AUTHORIZATION

Commuter Choice Program- Van Pool

Employee Name: _____________

CWID: _____________

___ *I hereby authorize my employer to deduct $________ from my wages on a pre-tax basis.

*NOT TO EXCEED IRS LIMITS PER MONTH

___ I hereby authorize my employer to deduct $______ from my wages on a post-tax basis.

___ I hereby cancel my deduction for the purchase the Commuter Choice Program-Van Pool effective _______________.

• *I understand that by participating in this voluntary program that my reported salary to the public employees retirement association (PERA) will be reduced by the above pre-tax dollar amount. This may reduce my highest average salary calculation and therefore adversely affect my retirement pay, should I retire within three years of the effective date of this authorization.

• I will be using the benefit for my regular daily commute from home to work and return. I will not give, barter, convey, or otherwise transfer this benefit to any other person.

• I understand and agree that false certification may result in corrective or disciplinary action taken by my employer up to and including dismissal from employment and possible prosecution for federal income tax evasion.

SIGNED: _________________________

DATE: _________________________

PHONE: _________________________

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